Intracranial hemorrhage due to vitamin K deficiency

Evidence-based case report Presented as scientific paper in Infection Unit Department of Child Health Medical School University of Sumatera Utara, Haji Adam Malik Hospital Medan. INTRACRANIAL HEMORRHAGE DUE TO VITAMIN K DEFICIENCY

Presentator Day/Date Supervisor in charge Consultant

: Dwi Novianti : Thursday / 18th December 2014 : dr. Yazid Dimyati, M.Ked(Ped), SpA(K) : Prof. dr. Bistok Saing, SpA(K) dr. Yazid Dimyati, M.Ked(Ped), SpA(K) dr. Johannes H. Saing, M.Ked(Ped), SpA(K) dr. Fereza Amelia, M.Ked(Ped), SpA

Introduction Vitamin K is a fat soluble vitamin essential for the function of several proteins involved in blood coagulation. Hemorrhages associated with vitamin K deficiency appear on the second or third day of life, with intracranial hemorrhages being the most serious neurologic consequences.1 Idiopathic vitamin K deficiency in infancy or acquired prothrombin complex deficiency (APCD) syndrome or vitamin K deficiency bleeding (VKDB), formerly known as “haemorrhagic disease of the newborn” (HDN) is a serious bleeding disorder in the early infantile period that was first described in 1966. Since then, this bleeding disorder has been reported from many parts of the world including North America, Europe, Australia, and Asia. In Thailand incidence reached 35.5 per 100 000 live births makes this disorder a public health problem for the nation.2 Clinical manifestations of intracranial hemorrhage in infancy varies according to the site of bleeding, most of APCD syndrome appear as subarachnoid, sub dural, and or intracerebral hemorrhages. The major presenting features are seizures, deppressed level of consciousness, and signs of increased intracranial pressure (e.g. tense fontanelle, vomiting).3 Internationally recommended criteria for defining “confirmed” VKDB in epidemiological studies include the following: age of onset, pretreatment coagulation studies which are grossly abnormal (prolongation of prothrombin time and activated partial thromboplastin time) despite normal platelet count and fibrinogen, or correction of coagulation results to normal after vitamin K administration.4 The injection of vitamin K prophylactic at birth has dramatically reduced the incidence of VKDB during the first weeks of life, but sporadic cases with late-onset hemorrhages are described among exclusively breastfed infants who did not receive prophylaxis vitamin K at birth.5

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The aim of this paper is to report a case of intra cranial hemorrhage due to vitamin K deficiency in an infant.

Case Baby AU, 29 days old was admitted to Emergency Departement of Haji Adam Malik Hospital on 11th July 2014 at 23.00 PM with seizure since 1 day before admitted. It was a generalized seizure, the frequency was 3 times and his mother describe it as repeated movements on hands and feet and eyes blinking that last for about 3 minutes. The baby did not cry nor open his eyes after the last seizure and refused to breastfeed. Fever was found one day before and along with the seizure. History of spontaneous bleeding was found, there was blood mixed with sputum came out of his mouth 2 times this morning. No history of trauma was found. He was born spontaneously, assisted by a midwife, aterm, no cyanosis was found and the baby cry immediately after birth. Birthweight was 3500 g, and he didn’t get vitamin K shot after birth. The mother was 29th years old, and this was her 2nd deliveries, with no history of any spesific illness throughout her pregnancy. No history of medication or herbal medicine consumption during pregnancy was found. The baby have had no immunization yet, and was breastfed but also got formula as his diet. The parent was advised by a midwife to brought their baby to Haji Adam Malik Hospital because of the seizure, with history of paracetamol syrup and diazepam administration per rectal.

Physical examination Consciousness: Somnolent, Glasgow Coma Scale (GCS) 13 (E3V4M6) T: 37.8°C anemic (+) icteric (-) cyanosis (-) dyspnea (-) oedema (-) Body weigth: 3700 g Body lenght: 51 cm Weigth for age: -2SD < z-score < 0 Length for age: -2SD < z-score < 0 Weight for length: 0 < z-score < 1SD General and disease condition: severe. Nutritional status: normal Head

: large fontanelle open and bulging, head circumference: 38 cm (-2